Original research
Prevalence of Diabetes and the Burden of Comorbid Conditions Among Elderly Nursing Home Residents

https://doi.org/10.1016/j.amjopharm.2011.05.001Get rights and content

Abstract

Background

Although the reported prevalence of diabetes in nursing home residents varies greatly among studies, there remains a common trend: increasing prevalence. Diabetes in the elderly is often associated with the presence of multiple comorbid conditions. However, limited data exist regarding the characteristics, symptom severity, disease management, and outcomes of care for residents of nursing homes with diabetes.

Objective

Our aim was to estimate the prevalence of diabetes in a national sample of skilled nursing facility (SNF) residents over a 12-month period and to examine differences in the burden of comorbidities between elderly residents with and without diabetes, including prevalence and severity of comorbidities, pharmacotherapy associated with these conditions, and cost.

Methods

This was a multicenter, observational, medical utilization evaluation study in 23 geographically representative SNFs in the United States. Comorbidities, cognition, physical activity, utilization of health services, and medications were obtained from medical chart audits, minimum data set records, and prescription claims files. Chart abstraction was performed between June 2006 and March 2007. Residents eligible for inclusion in the prevalence analysis were aged ≥65 years, did not receive hospice care, and were not in a persistent vegetative condition.

Results

A total of 2317 residents met the inclusion criteria and were included in the prevalence analysis; 761 (32.8%) had diabetes. Residents with a full minimum data set assessment within 12 months before chart abstraction (n = 2095) were included in the comorbid burden analysis. Compared with those without diabetes, a greater proportion of residents with diabetes were younger, male, Hispanic or African American, and were overweight or obese. Residents with diabetes had a greater comorbidity burden (Hierarchical Condition Category, 1.90 vs 1.58), including more prescribed medications for certain common comorbid conditions (including angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers [46% vs 24%], diuretics [44% vs 34%], statins [40% vs 18%], or antiplatelets/antithrombotics [43% vs 37%]), and experienced more hospitalizations (37% vs 18% at 6 months) than residents without diabetes.

Conclusion

Nearly one third of elderly SNF residents had diabetes. These patients, compared with SNF residents without diabetes, had a greater comorbid burden, were prescribed more medications to treat these conditions, and had more hospitalizations.

Introduction

Diabetes prevalence in the elderly has increased dramatically in the past decade and, at present, approximately 23.1% of Americans aged ≥60 years (12.2 million persons) are thought to have diabetes.1, 2 To compound matters, the percentage of those aged ≥65 years with diabetes is estimated to increase by 56% by 2020,3 and persons aged ≥55 years with diabetes are twice as likely as those without diabetes to reside in a nursing home.4 Although the reported prevalence for diabetes in nursing home residents varies greatly among studies (range, ∼7% to >30%),5, 6, 7, 8, 9, 10, 11, 12, 13, 14 a common trend remains: increasing prevalence. The number of residents in nursing homes with a diagnosis of diabetes doubled between the years 1964 and 19854 and is expected to continue to increase because of the aging population and the increased prevalence of diagnosed diabetes in all age groups.4, 15, 16 Diabetes now accounts for more than half of all nursing home admissions.9

Diabetes in the elderly is often associated with the presence of multiple comorbid conditions,4, 14, 15, 17, 18 and these chronic conditions may require additional medications.4 One study of older, inner-city African Americans found that those with diabetes took almost twice as many medications as those without diabetes.17 In addition, these medications may increase the risk of drug interactions and side effects, thus complicating the management of diabetes in the elderly.4

Furthermore, the cognitive decline associated with diabetes may impose an additional burden on the elderly. In a study of residents aged >55 years in a suburb of Rotterdam, Ott et al19 observed that diabetes was more prevalent among residents who developed dementia versus those who did not (relative risk [RR] = 1.9; 95% CI, 1.3–2.8). Diabetes was associated with decreases in the total cerebral brain volume ratio, which was linked to increased risk of stroke, poorer performance on cognitive tests, and brain atrophy.20 It also has been suggested that diabetes accelerates the aging process with respect to alterations in the unwinding rate of DNA, increased collagen crosslinking and free radical activity, cataracts, atherosclerosis, and an overall decrease in functional status.21

In addition to the physical and emotional burden that comorbidities impose, the presence of comorbid conditions among the elderly with diabetes can have significant economic consequences. Diabetes-related costs are projected to increase as the elderly and long-term care populations grow.3, 22

Despite the widespread burden of diabetes in elderly adults, limited data exist regarding the characteristics, symptom severity, disease management, and outcomes of care for residents with diabetes in nursing homes. Although it has been suggested that diabetes screening in the elderly is not justified because of reduced benefits of therapeutic intervention and life expectancy,11, 23 there is increasing evidence that glycemic control decreases morbidity in this population.21, 24 Specifically, effective glycemic control can reduce the risk for hyperosmolar nonketotic coma and mortality, and may improve patient quality of life.11 A reduction in diabetes-associated complications could have a beneficial impact on the associated costs. Unfortunately, concern about hypoglycemia in older patients is often a barrier to effective diabetes therapy.25 Glycemic control, however, is not necessarily the sole reason for hypoglycemia in nursing home residents.26, 27 The occurrence of hypoglycemia in elderly patients treated for diabetes has been shown to be related to overall health status, the presence of multiple comorbidities (eg, chronic renal or hepatic impairment), acute illness, polypharmacy, and poor nutrition.26, 27

Given the limited data on diabetes in elderly residents of nursing home facilities, the objectives of this study were to estimate the prevalence of diabetes in a national sample of skilled nursing facility (SNF) residents and to examine differences in the burden of comorbidities between elderly residents with and without diabetes. With a better understanding of the characteristics and needs of this population, clinicians may improve outcomes by becoming aware of the potential comorbid conditions and multiple medications patients with diabetes are likely to take. In doing so, it may be possible to develop strategies and protocols to ensure safe glycemic control in SNF residents. As with younger adults, efficient and effective glycemic control can reduce the likelihood of microvascular and macrovascular complications and, therefore, improve the overall quality of life for these long-term care residents.28, 29, 30 In addition, there is increasing evidence that insulin therapy, along with adequate blood glucose monitoring, can help older patients reach lower glycemic goals without an excessive risk of hypoglycemia.25, 31, 32, 33

Section snippets

Study Design and Population

This study was a multicenter, retrospective, noninterventional, observational medical utilization evaluation. Approximately 250 SNFs in the United States were identified in the facility selection pool as potential study sites. SNFs selected for participation were required to have current contracts with Omnicare, Inc. (Convington, Kentucky) for pharmacy services, and minimum data set (MDS, version 2.0; Centers for Medicare & Medicaid Services, Baltimore, Maryland) and prescription data

Site and Resident Disposition and Resident Demographics

This study was conducted at 23 Medicare- and Medicaid-certified sites. The sites were distributed geographically among the Northeast (21.7%), Midwest (30.4%), South (21.7%), and West (26.1%) regions of the United States. Almost half of the sites (11/23 [47.8%]) were part of a chain, and most sites (21/23 [91.3%]) were for-profit facilities. The average occupancy rate for the participating sites was 90.2%.

Of 2828 residents sampled, 2317 met eligibility criteria and were included in the analysis

Discussion

Results of this study found that nearly one third of the residents assessed in SNFs had diabetes. Greater proportions of residents with diabetes compared with residents not having diabetes were younger, male, Hispanic or African American, and overweight or obese. Although cognitive performance, physical functioning, and depression prevalence were similar between those with and without diabetes, those with diabetes were more likely to experience greater comorbid burden or be hospitalized.

Conclusions

In the present study, nearly one third of elderly SNF residents had diabetes. This patient population, compared with SNF residents without diabetes, had a greater comorbid burden, required more medications to treat the comorbidities, and had more hospitalizations.

Acknowledgments

This study was sponsored by and editorial support was provided by the sanofi-aventis US Group. The authors gratefully acknowledge Simi T. Hurst, PhD, who assisted in the preparation of this article based on author provided comments. The authors also thank Quanwu Zhang, PhD, for his assistance with statistical analysis, as well as Dr. Gary Erwin, for his input on the concept and development of this article. The authors have indicated that they have no conflicts of interest regarding the content

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